Provider Demographics
NPI:1093255390
Name:AMBROSE, JENI (PHDC)
Entity Type:Individual
Prefix:
First Name:JENI
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:PHDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80306-0683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3120 PEARL PKWY
Practice Address - Street 2:211
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2479
Practice Address - Country:US
Practice Address - Phone:805-679-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health